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Which of the following assists the critical care nurse in ensuring that care is appropriate and based on research?
- A. Clinical practice guidelines
- B. Computerized physician order entry
- C. Consulting with advanced practice nurses
- D. Implementing Joint Commission National Patient Safe ty Goals
Correct Answer: A
Rationale: The correct answer is A: Clinical practice guidelines. Clinical practice guidelines are evidence-based recommendations that assist nurses in providing appropriate care based on research. They outline best practices for specific patient populations or conditions, helping nurses make informed decisions.
Summary:
- B: Computerized physician order entry: While it may improve accuracy and efficiency, it does not specifically ensure care based on research.
- C: Consulting with advanced practice nurses: While collaboration is valuable, it does not guarantee care based on research.
- D: Implementing Joint Commission National Patient Safety Goals: Important for patient safety, but not directly related to ensuring care based on research.
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Which of the following statements regarding pain and anxiety are true? (Select all that apply.)
- A. Anxiety is a state marked by apprehension, agitation, a utonomic arousal, and/or fearful withdrawal.
- B. Critically ill patients often experience anxiety, but they rarely experience pain.
- C. Pain and anxiety are often interrelated and may be diffaibciurbl.tc otmo /tdeisft ferentiate because their physiological and behavioral manifestations are similar.
- D. Pain is defined by each patient; it is whatever the perso n experiencing the pain says it is.
Correct Answer: A
Rationale: Rationale:
A: Correct. Anxiety is characterized by apprehension, agitation, autonomic arousal, and fearful withdrawal, which are distinct from pain.
B: Incorrect. Critically ill patients can experience both anxiety and pain, as pain is not exclusive to them.
C: Incorrect. While pain and anxiety can be interrelated, they can be differentiated based on their unique physiological and behavioral manifestations.
D: Incorrect. Pain is a subjective experience, but it is not solely defined by the individual; objective assessments are also important.
The family is considering withdrawing life-sustaining measures from the patient. The nurse knows that ethical principles for withholding or withdrawi ng life-sustaining treatments include which of the following?
- A. Any treatment may be withdrawn and withheld, includ ing nutrition, antibiotics, and blood products.
- B. Doses of analgesic and anxiolytic medications must be adjusted carefully and should not exceed usual recommended limits.
- C. Life-sustaining treatments may be withdrawn while a patient is receiving paralytic agents.
- D. The goal of withdrawal and withholding of treatments is to hasten death and thus relieve suffering.
Correct Answer: A
Rationale: The correct answer is A because it aligns with the ethical principle of patient autonomy, which emphasizes the patient's right to make decisions about their own care. Withholding or withdrawing life-sustaining treatments, including nutrition, antibiotics, and blood products, respects the patient's autonomy. This choice also reflects the principle of beneficence, as it aims to prevent unnecessary suffering and respects the patient's wishes.
Option B is incorrect because it focuses on pain and anxiety management rather than the broader ethical considerations of withholding life-sustaining treatments.
Option C is incorrect because withdrawing life-sustaining treatments while a patient is receiving paralytic agents can pose additional risks and complications, potentially conflicting with the principles of nonmaleficence and beneficence.
Option D is incorrect because the primary goal of withdrawing or withholding treatments is not to hasten death but to respect the patient's autonomy and quality of life. This choice does not align with the ethical principles of patient-centered care.
Daily weights are being recorded for the patient with a urine output that has been less than the intravenous and oral intake. The weight yesterday was 97.5 kg. This morning it is 99 kg. The nurse understands that this corresponds to a(n)
- A. fluid retention of 1.5 liters.
- B. fluid loss of 1.5 liters.
- C. equal intake and output due to insensible losses.
- D. fluid loss of 0.5 liters.
Correct Answer: A
Rationale: The correct answer is A: fluid retention of 1.5 liters. The weight gain from 97.5 kg to 99 kg indicates an increase in fluid retention. This difference of 1.5 kg corresponds to fluid retention of 1.5 liters, as 1 liter of water weighs approximately 1 kg. This weight gain suggests that the patient is retaining more fluid than they are excreting, leading to an increase in weight.
Incorrect choices:
B: fluid loss of 1.5 liters - This is incorrect because the weight increased, indicating fluid retention.
C: equal intake and output due to insensible losses - This is incorrect as weight increased, showing an imbalance in intake and output.
D: fluid loss of 0.5 liters - This is incorrect as the weight increased, indicating fluid retention, not loss.
Which action will the nurse need to do when preparing to assist with the insertion of a pulmonary artery catheter?
- A. Determine if the cardiac troponin level is elevated.
- B. Auscultate heart and breath sounds during insertion.
- C. Place the patient on NPO status before the procedure.
- D. Attach cardiac monitoring leads before the procedure.
Correct Answer: D
Rationale: The correct answer is D: Attach cardiac monitoring leads before the procedure. This is essential to monitor the patient's cardiac rhythm and detect any abnormalities during catheter insertion. Cardiac monitoring leads provide real-time information on the patient's heart rate and rhythm, allowing the nurse to promptly address any complications.
A: Determining if the cardiac troponin level is elevated is not directly related to assisting with pulmonary artery catheter insertion.
B: Auscultating heart and breath sounds during insertion is important but does not take precedence over attaching cardiac monitoring leads.
C: Placing the patient on NPO status before the procedure may be necessary for other procedures, but it is not specifically required for assisting with pulmonary artery catheter insertion.
The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?
- A. Give intravenous (IV) calcium gluconate.
- B. Withhold the drug and notify the healthcare provider.
- C. Administer the dose as prescribed.
- D. Recheck the vital signs in 30 minutes and then administer the dose.
Correct Answer: C
Rationale: The correct answer is C: Administer the dose as prescribed. Verapamil is a calcium channel blocker used to treat atrial flutter. The vital signs obtained are within normal range for this medication. A heart rate of 92 and blood pressure of 110/76 are not contraindications for administering verapamil. Option A is incorrect as calcium gluconate is not indicated in this situation. Option B is incorrect because the vital signs are stable and do not warrant withholding the medication. Option D is incorrect as there is no need to delay the administration of verapamil based on the vital signs provided.